Plan Information

Discount Fee Schedule

The below discounts contained in this Fee Schedule are valid only when treatment is provided by a Participating General Dentist. If the services of a Participating Specialist are recommended and available, then the above discounts DO NOT apply and the member's charge will be the Participating Specialist's usual and customary fee, less a discount of 25%. If a service is not listed above, it may be available at the Participating Dental Provider's usual and customary fee, less a discount of 25%.

The following is a summary representation of the plan offered. For a full detail, please download your Discount Fee Schedule.

Plan Features

Diagnostic

Clinical Oral Evaluation

You Pay

D0120

periodic oral evaluation - established patient

$20

D0140

limited oral evaluation - problem focused

$40

D0145

oral evaluation for a patient under three years of age and counseling with primary caregiver

Reduction of Dislocation and Management of Other Temporomandibular Joint Dysfuctions

You Pay

D7880

occlusal orthotic device, by report

$375

Other Repair Procedures

You Pay

D7940

osteoplasty - for orthognathic deformities

$2,300

D7950

osseous, osteoperiosteal, or cartilage graft of the mandible or maxilla - autogenous or nonautogenous, by report

$1,199

D7960

frenulectomy (frenectomy or frenotomy) - separate procedure

$185

D7963

frenuloplasty

$185

D7970

excision of hyperplastic tissue - per arch

$185

D7971

excision of pericoronal gingiva

$80

D7983

closure of salivary fistula

$1,312

Orthodontics

Limited Orthodontic Treatment

You Pay

D8010

limited orthodontic treatment of the primary dentition

$1,500

D8020

limited orthodontic treatment of the transitional dentition

$1,500

D8030

limited orthodontic treatment of the adolescent dentition

$1,500

D8040

limited orthodontic treatment of the adult dentition

$1,500

Comprehensive Orthodontic Treatment

You Pay

D8070

comprehensive orthodontic treatment of the transitional dentition

$2,950

D8080

comprehensive orthodontic treatment of the adolescent dentition

$2,950

D8090

comprehensive orthodontic treatment of the adult dentition

$2,950

Other Orthodontic Services

You Pay

D8660

pre-orthodontic treatment visit

$45

D8670

periodic orthodontic treatment visit (as part of contract)

$45

D8680

orthodontic retention (removal of appliances, construction and placement of retainer(s))

$400

Adjunctive General Services

Unclassified Treatment

You Pay

D9110

palliative (emergency) treatment of dental pain-minor procedure

$40

Anesthesia

You Pay

D9210

local anesthesia not in conjunction with operative or surgical procedures

$25

D9211

regional block anesthesia

$28

D9212

trigeminal division block anesthesia

$54

D9220

deep sedation/general anesthesia-first 30 minutes

$210

D9221

deep sedation/general anesthesia-each additional 15 minutes

$80

D9230

analgesia, anxiolysis, inhalation of nitrous oxide

$50

D9241

intravenous conscious sedation/analgesia-first 30 minutes

$185

D9242

intravenous conscious sedation/analgesia-each additional 15 minutes

$70

D9248

non-intravenous conscious sedation

$54

Professional Consultation

You Pay

D9310

consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician

$45

Professional Visits

You Pay

D9410

house/extended care facility call

$175

D9420

hospital call

$175

D9440

office visit-after regularly scheduled hours

$75

Drugs

You Pay

D9610

therapeutic parenteral drug, single administration

$35

D9612

therapeutic parenteral drug, two or more administrations, different medications

$50

D9630

other drugs and/or medicaments, by report

$25

Miscellaneous Services

You Pay

D9910

application of desensitizing medicament

$25

D9941

fabrication of athletic mouthguard

$100

D9950

occlusion analysis - mounted case

$95

D9951

occlusal adjustment - limited

$50

D9952

occlusal adjustment - complete

$295

D9970

enamel microabrasion

$32

D9972

external bleaching - per arch

$200

D9973

external bleaching - per tooth

$22

D9974

internal bleaching - per tooth

$148

*This Plan is not insurance and does not make payments directly to providers of service. The Plan member is obligated to pay for all health care services and will receive a discount from providers who participate in the network.

Plan Summary

More Information

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